Imaginator: a Pilot of a Brief Functional Imagery Training Intervention for Self-harm

Summary

Self-harm has substantial personal impacts as well as costs on the NHS. Around 13-17% of
young people report experiences of self-harm. In Cambridgeshire, this is a significant issue
with the number of admissions to hospital for self-harm in young people being higher than
the UK average. Treating underlying mental illness can lead to a reduction in self-harm, but
these are long interventions for complex disorders and many people who self-harm are not
under treatment for mental illness. Moreover, young people struggle to access traditional
mental health services where these therapies are delivered. No short interventions
specifically tailored for young people have been developed so far.

The IMAGINATOR project aims to address the urgent need for an effective and innovative
short-term therapy for self-harm in young people. The investigators will pilot a new
imagery-based psychological intervention for young people aged 16-25 who experience
repetitive self-harm. Mental imagery (the experience of "seeing through the mind's eye") can
carry intense emotions (positive and negative), and imagining something can facilitate
behaviour. Imagery-based therapies have proven useful (i) for problems that feature intense,
hard to manage emotions such as those associated with self-harm, and (ii) for promoting
healthy behaviour. Our new intervention called Functional Imagery Training will support
young people to imagine more adaptive behaviours to cope with the emotional distress that
triggers self-harm, and motivate them to reduce self-harm. IMAGINATOR will comprise of just
two sessions followed by phone support over three months.

Moreover, the investigators will address the challenge of young people accessing and staying
in therapy by using a smartphone app to support the therapy, as apps are widely used and
favoured by this age group. The app will enable participants to continue with the strategies
they have learnt in therapy by themselves, thus ensuring a potential longer-term benefit and
self-empowerment.

Description

The problem of self-harm and the need short interventions for young people.

Self-harm, an "act of self-poisoning or self-injury, irrespective of the apparent purpose of
the act" (www.nice.org.uk/guidance/cg133) is a behaviour used to cope with intense emotions
and psychological distress. It can occur in a variety of mental health diagnoses as well as
individuals with no diagnosis. Of concern is that almost one in five young adults report
self-harm behaviour (Swannell, Martin et al. 2014). A UK survey in schools described 13%
15-16 years old had self-harmed during their life and 8% in the last year (Hawton, Rodham et
al. 2002). Factors associated with self-harm include a disadvantaged socio-economic
background, social isolation and lack of support, negative life events including childhood
emotional, physical or sexual abuse. Although self-harm is different from suicidality,
people who self-harm carry a fourfold risk of suicidal thoughts and behaviours within one
year, a risk over and above risk conferred by mental health problems and psychosocial risk
factors (Whitlock, Muehlenkamp et al. 2013).

Self-harm has substantial personal impacts and costs on the NHS (www.nccmh.org.uk). In
Cambridgeshire, the number of hospital admissions for self-harm has been higher than the UK
average, making addressing self-harm a significant issue for local primary and secondary
health care NICE guidelines recommend offering a "psychological intervention that is
specifically structured for people who self-harm, with the aim of reducing self-harm. In
addition: (i) the intervention should be tailored to individual need, and could include
cognitive-behavioural, psychodynamic or problem-solving elements; (ii) therapists should be
trained and supervised in the therapy they are offering to people who self-harm; (iii)
therapists should also be able to work collaboratively with the person to identify the
problems causing distress or leading to self-harm." A number of interventions have been
developed and have shown some efficacy at reducing self-harm in adolescents and adults
(Cochrane reviews: Hawton, 2015 and Hawton, 2016). However these therapies vary between 4
sessions and much longer duration, and currently are mostly available only to individuals
under mental health care after variable periods of waiting time. Moreover, almost half of
young people referred recommended treatment will not attend any follow-up sessions
(Granboulan et al., 2001). There is a lack of short interventions for self-harm specifically
targeted at young people (Kendall, Taylor et al. 2011). Short interventions that engage
young people are urgently needed to allow young people to better manage and reduce self-harm
also outside secondary mental health care, and alongside / while waiting for more longterm
problems to be addressed (psychiatric disorders, housing and employment difficulties etc.).

Developing new treatments for self-harm using imagery-based interventions.

Mental imagery is the process of 'seeing through the mind's eye'. Intrusive mental images
carrying intense negative emotions are central to several mental disorders (Holmes and
Mathews 2010). For example, individuals with social anxiety will experience intrusive images
of them sweating and blushing intensely while they try to speak to someone, these images
will fuel their anxiety about being judged by others and possibly stop them from attending
further social situations. Mental imagery associated with self-harm also appears to be a
common phenomenon and individuals describe that images associated with self-harm can carry
many different emotional meanings (e.g. evoking a sense of relief, or increasing the urge to
self-harm), in line with what drives self-harm in every individual (Dargan et al., 2016).
The characteristics of mental images are related to the intensity of emotions and this
applies to positive emotions too. For example, more vivid positive imagery has been related
to greater excitement during positive mood (Ivins et al., 2014). Overall, this suggests that
mental imagery is a common phenomenon, which many individuals are likely to experience in
the context of high emotions, and that mental images could be used to generate helpful
emotions. In fact, addressing distressing mental images and promoting positive imagery has
been used for trauma (http://www.nice.org.uk/CG26), depression (Brewin, Wheatley et al.
2009, Blackwell et al., 2014) and self-harm in personality disorders (Bamelis, Evers et al.
2014). The investigators have successfully treated cases with self-harm behaviour using a
short course of imagery-focused therapy for Bipolar Disorder (Holmes, Bonsall et al. 2016).

Moreover, mental images can promote behaviour. Imagining something makes it more likely to
act, because it simulating the actual event in the mind and it allows individuals to
''pre-experience'' all aspects the event (Moulton and Kosslyn 2009). Hence, via imagining
future scenarios individuals may feel more ready to engage in the action succesfully. For
example, in sports adding mental imagery training (visualing an exercise) to physical
practice of an exercise improves performance (Schuster et al., 2011). Moreover, imagining an
action also involves anticipating how emotionally rewarding it is likely to be. This may
enhance motivation to act. The more vivid and real-like the mental image of completing a
desired action is, the stronger the positive emotion and motivation to actually do it. This
type of imagery of healthy behaviour and desired actions has been developed into a therapy
called Functional Imagery Training (FIT - Andrade, May, & Kavanagh, 2012). FIT encourages
individuals to imagine the benefits of working towards their goals, especially the benefits
that are expected to happen right away (e.g. feeling good about oneself).

So far, FIT has been shown to be a successful approach for interventions to reduce snacking
and in addictive behaviours.

Based on this, the investigators propose that FIT can train individuals to imagine more
helpful behaviours rather than self-harm when distressed. FIT will train vivid and real-like
imagery of alternative goals to self-harm, which is likely to produce rewarding and positive
emotions. Our FIT protocol will aim to support individuals who self-harm at:

(i) identifying helpful behaviours as an alternative goal when they feel like self-harming
(e.g. going for a run, listening to music); (ii) by practising mental imagery of the
alternative behaviour, boosting the desire to achieve this goal; (iii) succeeding in
engaging in alternative behaviours to self-harm.

Importantly, FIT will consist of two face-to-face sessions plus five brief telephone support
sessions. Therefore it has the potential of offering immediate support for all those young
people who are either excluded from or waiting for more complex interventions.

The challenge of engaging young people.

Imagery-based interventions focus on visual techniques and are easily amenable to be
supported by a smartphone app. Smartphone usage by young people is high. Therefore,
enhancing a psychological intervention via a smartphone app could be a successful strategy
to ensure that young people keep practising the therapy techniques and engaging with what
was learned in therapy once the sessions are over and without the need of face to face
follow-up. The support of a smartphone app following the FIT sessions can aid overcome
barriers to engagement reported in young people.

Therefore, the IMAGINATOR study will tailor FIT to young people by adding a smartphone app
support, which can make the intervention more interesting and approachable to this age
group. The investigators have developed a bespoke app called Imaginator. This app was
created collectively via six meetings of a Young People Advisory Group (YPAG: 4 members, 1
male, aged 19 to 22 years old, with a lived experience of self-harm), together with the
research team and John Harper, from App Shine Development company.

In summary, self-harm behaviour is a highly prevalent problem among young people in the UK
(and worldwide), and of particular urgency in Cambridgeshire. It represents a major social
and healthcare problem for the community. Currently, there is a lack of short and easily
accessible interventions to specifically help young people reduce self-harming behaviour. As
mental imagery-based techniques have been used to reduce unwanted emotions and support
motivation and helpful behaviour, The investigators propose that Functional Imagery Training
(FIT) could represent a successful strategy to reduce self-harm behaviour. FIT is intended
as a brief and focused intervention for young people aged 16-25 (regardless of any
diagnosis) that can be added to any other pharmacological or psychological therapy. To
improve access to and engagement with the intervention by young people, the investigators
will deliver FIT supported by a smartphone app developed together with a Young People
Advisory Group.

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Medical and Biotech [MESH] Definitions

Imagery (psychotherapy)

The use of mental images produced by the imagination as a form of psychotherapy. It can be classified by the modality of its content: visual, verbal, auditory, olfactory, tactile, gustatory, or kinesthetic. Common themes derive from nature imagery (e.g., forests and mountains), water imagery (e.g., brooks and oceans), travel imagery, etc. Imagery is used in the treatment of mental disorders and in helping patients cope with other diseases. Imagery often forms a part of HYPNOSIS, of AUTOGENIC TRAINING, of RELAXATION TECHNIQUES, and of BEHAVIOR THERAPY. (From Encyclopedia of Human Behavior, vol. 4, pp29-30, 1994)

Self-injurious Behavior

Behavior in which persons hurt or harm themselves without the motive of suicide or of sexual deviation.

Dangerous Behavior

Actions which have a high risk of being harmful or injurious to oneself or others.

Training Support

Financial support for training including both student stipends and loans and training grants to institutions.

Child Rearing

The training or bringing-up of children by parents or parent-substitutes. It is used also for child rearing practices in different societies, at different economic levels, in different ethnic groups, etc. It differs from PARENTING in that in child rearing the emphasis is on the act of training or bringing up the child and the interaction between the parent and child, while parenting emphasizes the responsibility and qualities of exemplary behavior of the parent.

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